Signature Sheet for Interventions by Risk Level Plan of ...



|SIGNATURE SHEET FOR INTERVENTIONS BY RISK LEVEL PLAN OF CARE, PART 3 |

|Michigan Department of Health and Human Services |

|Maternal Infant Health Program |

|Beneficiary |Case Manager |

|      |      |

|We, the undersigned, have reviewed the risk identifier, participated in case consultation and have assisted in development of the plan of care. We concur with the |

|approach to case management and implementation of the interventions. |

|INITIAL PLAN OF CARE |

|Registered Nurse Signature/Credentials |Date |

| |      |

|Licensed Social Worker Signature/Credentials |Date |

| |      |

|Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant) |Date |

| |      |

|CARE PLAN REVISIONS |

|Domain |

|      |

|Registered Nurse Signature/Credentials |Date |

| |      |

|Licensed Social Worker Signature/Credentials |Date |

| |      |

|Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant) |Date |

| |      |

|Domain |

|      |

|Registered Nurse Signature/Credentials |Date |

| |      |

|Licensed Social Worker Signature/Credentials |Date |

| |      |

|Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant) |Date |

| |      |

| |

|The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, |

|color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. |

|SIGNATURE SHEET FOR INTERVENTIONS BY RISK LEVEL PLAN OF CARE, PART 3 INSTRUCTIONS |

|These instructions are intended to clarify data fields. Questions can be answered by an MIHP state consultant. |

|Initial Plan of Care 2 |

|The top section documents that the two required disciplines (at a minimum) have developed, reviewed and concur with the beneficiary’s initial POC 2. The nurse and social|

|worker do not sign the POC 3 until they have reviewed the electronic Risk Identifier in its entirety and pulled the appropriate risk domains to compile the beneficiary’s|

|POC 2. |

|When entering dates, use the preferred format: MM/DD/YYYY. |

|Beneficiary: Insert beneficiary’s first and last name. |

|Case Manager: Insert the first and last name of the case manager (RN or SW); credentials are not required. If the case manager changes during the course of care, cross |

|out the name of the previous case manager and add the name of the new one. Initial and date this change. Electronic medical record systems will do this automatically. |

|Registered Nurse Signature/Credentials: Sign first and last name and credential. Include license in credentials (RN). Signature must be dated within 10 business days of |

|licensed social worker’s signature. |

|Date: Insert date of signature. |

|Social Worker Signature/Credentials: Sign first and last name and credentials. Include license in credential (LLBSW, LLMSW, LBSW, or LMSW). Signature must be dated |

|within 10 business days of registered nurse’s signature. |

|Other Disciplines Contribution to POC: The Registered Dietitian (RD), Infant Mental Health Specialist (IMHS), or IBCLC Lactation Consultant signs and dates here if they |

|participated in development of the original POC 2. |

|Care Plan Revisions |

|Two additional sections document that a risk domain has been added to the POC 2 because the beneficiary’s situation matches the risk criteria in Column 2 of the POC 2. |

|Domain: Insert the title of the risk domain that has been added to the POC 2. |

|Registered Nurse Signature/Credentials: Sign first and last name and credential. Include license in credentials (RN). Signature must be dated within 10 business days of |

|licensed social worker’s signature. |

|Date: Insert date of signature. |

|Social Worker Signature/Credentials: Sign first and last name and credentials. Include license in credential (LLBSW, LLMSW, LBSW, or LMSW). Signature must be dated |

|within 10 business days of registered nurse’s signature. |

|Other Disciplines Contribution to POC: The Registered Dietitian (RD), Infant Mental Health Specialist (IMHS), or IBCLC Lactation Consultant participates in the decision |

|to add a domain to the POC 2, they sign here and enter the date. |

|If Agency is Missing a Discipline |

|Beneath the signature line, write: Agency is without SW (or RN) or in process of hire or other language that indicates the agency is devoid of one discipline at the time|

|the POC 2 was developed. |

|When the replacement SW or RN is hired, he or she should review and sign the POC 3 on or near the signature line with the current date, indicating concurrence with the |

|POC 2. |

|Notifying Medical Care Provider that Maternal Considerations Domain Has Been Added |

|When the beneficiary is an infant and there is a change in maternal risk, add a new Maternal domain, update and sign the POC 3. If the newly-identified risk is one that |

|may affect the infant’s care (e.g., substance misuse, domestic violence, etc.), it is recommended that the infant’s medical care provider be alerted, if the mother has |

|consented. Some MIHP providers have policies that expressly prohibit the sharing of maternal information with the infant’s medical care provider. |

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